Emergency Department Evaluation of Young Infants With Head Injury.

OBJECTIVES: We compared the emergency department (ED) evaluation and outcomes of young head-injured infants to older children. METHODS: Using the Pediatric Health Information Systems database, we performed a retrospective, cross-sectional analysis of children <2 years old with isolated head injuries (International Classification of Diseases, 10th Revision, diagnoses) at one of 47 EDs from 2015 to 2019. Our primary outcome was utilization of diagnostic cranial imaging. Secondary outcomes were diagnosis of traumatic brain injury (TBI), clinically important TBI, and mortality. We compared outcomes between the youngest infants (<3 months old) and children 3 to 24 months old. RESULTS: We identified 112 885 ED visits for children <2 years old with isolated head injuries. A total of 62 129 (55%) were by males, and 10 325 (9.1%) were by infants <3 months of age. Compared with older children (12-23 months old), the youngest infants were more likely to: Undergo any diagnostic cranial imaging (50.3% vs 18.3%; difference 31.9%, 95% confidence interval [CI] 35.0-28.9%), be diagnosed with a TBI (17.5% vs 2.7%; difference 14.8%, 95% CI 16.4%-13.2%) or clinically important TBI (4.6% vs 0.5%; difference 4.1%, 95% CI 3.8%-4.5%), and to die (0.3% vs 0.1%; difference 0.2%, 95% CI 0.3%-0.1%). Among those undergoing computed tomography or MRI, TBIs were significantly more common in the youngest infants (26.4% vs 8.8%, difference 17.6%, 95% CI 16.3%-19.0%). CONCLUSIONS: The youngest infants with head injuries are significantly more likely to undergo cranial imaging, be diagnosed with brain injuries, and die, highlighting the need for a specialized approach for this vulnerable population.

Determination, categorization, and hierarchy of content for a pediatric emergency medicine curriculum designed for emergency medicine residents.

Background: Currently, the Accreditation Council of Graduate Medical Education requires time-based pediatric experiences for emergency medicine (EM) residents in both pediatric emergency medicine (PEM) and critical care settings. The American Board of Emergency Medicine has published the Model of the Clinical Practice of Emergency Medicine, which is a list of content an EM resident should learn. However, this list is large and without prioritization and therefore can be difficult to incorporate into time-limited curricula. Objectives: The primary objective of this study was to develop comprehensive categorization of PEM content using an EM lens. The second objective was to suggest a prioritization for the EM learner of the enumerated PEM elements. Methods: We first assembled a comprehensive list of PEM concepts, diagnoses, and procedures that might be taught to EM residents. We then convened focus groups composed of key stakeholders to help formulate content and concept themes important for EM resident training. Once the themes were identified, we divided the list of PEM topics into appropriate themes and then carried out a second round of focus groups expanded to include more diverse expert input for prioritizing the elements of the comprehensive list within each theme. Results: We prioritized 168 important PEM concepts from previous standards and emerging PEM literature among 10 identified themes: the pediatric normal, the bottom-line boil-it-down approach, common presentations, high-acuity pediatric cases and procedures, differences between children and adults, same between children and adults, red flags, infrequency of caring for a child compared with an adult, keep breadth but promote self-directed depth, and triage and disposition. Conclusions: Based on input from stakeholders in EM resident education, we identified key themes within PEM education and created a framework for the hierarchical categorization of PEM content for within an EM residency.

Alternative care sites and resident exposure in pediatric emergency medicine: Who, what, and where.

Objectives: Emergency medicine (EM) physicians and pediatricians who provide acute pediatric care depend on clinical exposure during residency to learn pediatric EM. Increasing volumes of pediatric patients, especially with behavioral health complaints, have stressed pediatric emergency departments (ED) and prompted clinical operations innovations including alternative care sites outside the main ED. We investigated the impact of these recent trends and resulting alternative care sites on the exposure of residents to core pediatric conditions. Methods: This retrospective study reviewed patient encounters between July 1, 2018, and December 31, 2022, at a pediatric ED that hosts one pediatric and three EM residencies. During the study, the hospital employed alternative care sites in response to increased and shifting patient populations. Median patients per resident per academic year were compared before and after the opening of alternative care sites, overall and stratified by patient factors (age, sex, Emergency Severity Index [ESI], and diagnostic category). The study also compared the percentage of residents who saw no patients with a given diagnosis between the two periods. Results: Of 231,101 patient encounters, 199,947 were seen in the main ED and 31,154 in alternative care sites. The median number of patients seen by a single resident in a single academic year ranged from 82 to 136 for pediatric residents and from 128 to 183 for EM residents. The median number of patients per resident per year did not decrease for any age group, sex, ESI level, or diagnosis across the two periods. Residents saw a median of 19 more patients with psychiatric diagnoses (95% CI 15.4-22.7) in the more recent period. Seven diagnoses were not seen by at least 20% of residents during both periods. Conclusions: Current pediatric ED capacity challenges can be addressed with alternative care sites without decreasing volume or variety of patients seen by residents.

Pediatric Traumatic Injury Emergency Department Visits and Management in US Children's Hospitals From 2010 to 2019.

STUDY OBJECTIVE: To examine trends in trauma-related pediatric emergency department (ED) visits and management in US children's hospitals over 10 years. METHODS: This is a retrospective, descriptive study of the Pediatric Health Information Systems database, including encounters from 33 US children's hospitals. We included patients aged 0 to 19 years with traumatic injuries from 2010 to 2019 identified using International Classification of Diseases-9 and -10 codes. The primary outcome was prevalence of trauma-related ED visits. The secondary outcomes included ED disposition, advanced imaging use, and trauma care costs. We examined trends over time with Poisson regression models, reporting incidence rate ratios (IRRs) with 95% confidence intervals (CIs). We compared demographic groups with rate differences with 95% CIs. RESULTS: Trauma-related visits accounted for 367,072 ED visits (16.3%) in 2010 and 479,458 ED visits (18.1%) in 2019 (IRR 1.022, 95% CI 1.018 to 1.026). From 2010 to 2019, 54.6% of children with traumatic injuries belonged to White race and 23.9% had Hispanic ethnicity. Institutional hospitalization rates (range 3.8% to 14.9%) decreased over time (IRR 0.986, 95% CI 0.977 to 0.994). Hospitalizations from 2010 to 2019 were higher in White children (8.9%) than in children of other races (6.4%) (rate difference 2.56, 95% CI 2.51 to 2.61). Magnetic resonance imaging for brain (IRR 1.05, 95% CI 1.04 to 1.07) and cervical spine (IRR 1.03, 95% CI 1.02 to 1.05) evaluation increased. The total trauma care costs were $6.7 billion, with median costs decreasing over time. CONCLUSION: During the study period, pediatric ED visits for traumatic injuries increased, whereas hospitalizations decreased. Some advanced imaging use increased; however, median trauma costs decreased over time.

The Infant Scalp Score: A Validated Tool to Stratify Risk of Traumatic Brain Injury in Infants With Isolated Scalp Hematoma.

OBJECTIVES: The objective was to validate the previously derived Infant Scalp Score (ISS) that uses clinical signs in infants with isolated scalp hematoma (ISH) after head trauma to stratify risk for clinically important traumatic brain injury (ciTBI) or TBI on computed tomography (CT). METHODS: Using the publicly available Pediatric Emergency Care Applied Research Network TBI data set, we selected infants ≤ 1 year with GCS 14 to 15 who had ISH (defined as hematoma without other signs/symptoms of TBI). CT scans were obtained at the treating physician's discretion. We calculated ISS based on age, hematoma size, and location (range = 0-8) for each patient and calculated the sensitivity and specificity of the score for ciTBI and TBI on CT across a range of ISS cut-points. RESULTS: We included 1,289 infants ≤ 1 year of whom 462 (36%) had CT performed. Twelve had ciTBI and 59 had TBI on CT. An ISS cutoff ≥ 4 had sensitivity of 100% for ciTBI (95% confidence interval [CI] = 0.74 to 1.0) and TBI with specificity of 0.49 (95% CI = 0.46 to 0.51). An ISS cutoff of ≥5 had a sensitivity of 100% for ciTBI (95% CI = 0.74 to 1.0) and specificity of 0.68 (95% CI = 0.66 to 0.71), but missed three infants with TBI on CT (none of whom required intervention). The receiver operating characteristic curves for clinical score to detect ciTBI and TBI had areas under the curve of 0.916 and 0.807, respectively. CONCLUSIONS: The ISS accurately stratified risk for ciTBI and TBI on CT in infants with ISH and is a useful tool to help guide clinical decision making.

Use of Ondansetron for Vomiting After Head Trauma: Does It Mask Clinically Significant Traumatic Brain Injury?

OBJECTIVES: We describe ondansetron use in children with head injury evaluated in pediatric emergency departments and its association with return visits and late diagnoses of intracranial injuries requiring intervention. METHODS: Children ages 6 months to 18 years discharged without neuroimaging from 35 pediatric emergency departments with a diagnosis of head injury from 2009 to 2013 were identified retrospectively from the Pediatric Health Information System. We evaluated the rates of ondansetron use during the study period and of the association of ondansetron treatment with the diagnosis of intracranial injury, skull fracture, and return visits within 72 hours requiring admission or operative intervention. RESULTS: We identified 218,904 encounters during the study period. Of these, 5894 patients (2.8%) were given ondansetron. There was significant variation in the use of ondansetron during the index visit between hospitals (0.1%-5.7%), and ondansetron use significantly increased over the study period. Return visits within 72 hours were more likely for patients treated with ondansetron during the index visit (3.7% vs 1.9%; adjusted odds ratio, 1.99; 95% confidence interval, 1.7-2.4). These patients were more likely to be admitted than those not treated initially with ondansetron (7% vs 4%; adjusted odds ratio, 1.97; 95% confidence interval, 1.09-3.55). There were no significant differences in rates of skull fractures, intracranial injury, intensive care unit admission, or operative intervention between groups. CONCLUSIONS: Ondansetron use during an initial emergency department visit for head trauma in children not requiring neuroimaging is associated with a higher likelihood of return within 72 hours and subsequent admission. There were no differences in rates of missed skull fractures, intracranial injury, intensive care admission, or operative intervention for groups who were and were not treated with ondansetron; however, this study was underpowered to detect significant differences in these categories. Future investigations with greater numbers would be required to confidently assess these critical differences.

Motor Vehicle Crash Fatalities in States With Primary Versus Secondary Seat Belt Laws: A Time-Series Analysis.

BACKGROUND: Motor vehicle crashes (MVCs) remain a leading cause of injury-related deaths in the United States. Primary seat belt laws allow vehicle occupants to be ticketed solely for not wearing seat belts, and secondary laws allow ticketing only for failure to wear seat belts in the setting of other violations. OBJECTIVE: To determine the association between MVC fatality rates and primary versus secondary seat belt laws. DESIGN: Retrospective time-series analysis. SETTING: United States, 2001 to 2010. PARTICIPANTS: MVC fatalities in occupants aged 10 years or older identified in the Fatality Analysis Reporting System. MEASUREMENTS: Population-based rates of fatal crashes. RESULTS: There were 283 183 MVC fatalities in occupants aged 10 years or older from 2001 to 2010 (overall rate, 13.0 per 100 000 persons). In 2001, the mean fatality rate was 14.6 per 100 000 persons, 16 states had primary seat belt laws, and 33 states had secondary laws. In 2010, the mean fatality rate was 9.7 per 100 000 persons, 30 states had primary seat belt laws, and 19 states had secondary laws. In the multivariate regression model, states with primary seat belt laws had lower MVC fatality rates than states with secondary laws (adjusted incidence rate ratio, 0.83 [95% CI, 0.78 to 0.90]). LIMITATION: Only fatalities were analyzed from the database, and the degree of law enforcement could not be ascertained. CONCLUSION: States with primary seat belt laws had lower rates of MVC fatalities than those with secondary laws. Adoption of primary seat belt laws may offer optimal occupant protection. PRIMARY FUNDING SOURCE: None.

Risk of traumatic brain injuries in children younger than 24 months with isolated scalp hematomas.

STUDY OBJECTIVE: We aimed to determine the association between scalp hematoma characteristics and traumatic brain injuries in young children with blunt head trauma who have no other symptoms or signs suggestive of traumatic brain injuries (defined as "isolated scalp hematomas"). METHODS: This was a secondary analysis of children younger than 24 months with minor blunt head trauma from a prospective cohort study in 25 Pediatric Emergency Care Applied Research Network emergency departments. Treating clinicians completed a structured data form. For children with isolated scalp hematomas, we determined the prevalence of and association between scalp hematoma characteristics and (1) clinically important traumatic brain injury (death, neurosurgery for traumatic brain injury, intubation >24 hours for traumatic brain injury, or positive computed tomography (CT) scan in association with hospitalization ≥2 nights for traumatic brain injury); and (2) traumatic brain injury on CT. RESULTS: Of 10,659 patients younger than 24 months were enrolled, 2,998 of 10,463 (28.7%) with complete data had isolated scalp hematomas. Clinically important traumatic brain injuries occurred in 12 patients (0.4%; 95% confidence interval [CI] 0.2% to 0.7%); none underwent neurosurgery (95% CI 0% to 0.1%). Of 570 patients (19.0%) for whom CTs were obtained, 50 (8.8%; 95% CI 6.6% to 11.4%) had traumatic brain injuries on CT. Younger age, non-frontal scalp hematoma location, increased scalp hematoma size, and severe injury mechanism were independently associated with traumatic brain injury on CT. CONCLUSION: In patients younger than 24 months with isolated scalp hematomas, a minority received CTs. Despite the occasional presence of traumatic brain injuries on CT, the prevalence of clinically important traumatic brain injuries was very low, with no patient requiring neurosurgery. Clinicians should use patient age, scalp hematoma location and size, and injury mechanism to help determine which otherwise asymptomatic children should undergo neuroimaging after minor head trauma.

Isolated skull fractures: trends in management in US pediatric emergency departments.

STUDY OBJECTIVE: Previous studies have suggested that children with isolated skull fractures are at low risk of requiring neurosurgical intervention, suggesting that admission to the hospital may not be necessary in many instances. We seek to evaluate current practice for children presenting to the emergency department (ED) for isolated skull fractures in US children's hospitals. METHODS: We conducted a retrospective multicenter cross-sectional study of children younger 19 years with a diagnosis of isolated skull fracture who were evaluated in the ED from 2005 to 2011, using the Pediatric Health Information System database. The primary outcome measure was the rate of hospital admission. Secondary outcomes were any neurosurgical procedure during hospitalization, repeated neuroimaging, duration of hospitalization, and cost of care. RESULTS: We identified 3,915 patients with isolated skull fractures, of whom 60% were male patients; 78% were hospitalized. Of hospitalized children, 85% were discharged within 1 day and 95% were discharged within 2 days. During hospitalization, 47 patients received repeated computed tomography imaging and 1 child required a neurosurgical procedure. Hospital costs were more than triple for hospitalized patients compared with patients discharged from the ED ($2,064 versus $619). CONCLUSION: Most children treated in EDs of US children's hospitals with isolated skull fractures are hospitalized. The rate of neurosurgical intervention is very low. A better understanding of current practice is necessary to assess whether these admissions are warranted or not.

Pediatric traumatic brain injury and radiation risks: a clinical decision analysis.

OBJECTIVE: To determine the optimal imaging strategy for young children with minor head injury considering health-related quality of life and radiation risk. In children with minor head trauma, the risk of missing a clinically important traumatic brain injury (ciTBI) must be weighed against the risk of radiation-induced malignancy from computed tomography (CT) to assess impact on public health. STUDY DESIGN: We included children <2 years old with minor blunt head trauma defined by a Glasgow Coma Scale score of 14-15. We used decision analysis to model a CT-all versus no-CT strategy and assigned values to clinical outcomes based on a validated health-related quality of life scale: (1) baseline health; (2) non-ciTBI; (3) ciTBI without neurosurgery, death, or intubation; and (4) ciTBI with neurosurgery, death, or intubation >24 hours with probabilities from a prospective study of 10000 children. Sensitivity analysis determined the optimal management strategy over a range of ciTBI risk. RESULTS: The no-CT strategy resulted in less risk with the expected probability of a ciTBI of 0.9%. Sensitivity analysis for the probability of ciTBI identified 4.8% as the threshold above which CT all becomes the preferred strategy and shows that the threshold decreases with less radiation. The CT all strategy represents the preferred approach for children identified as high-risk. CONCLUSION: Among children <2 years old with minor head trauma, the no-CT strategy is preferable for those at low risk, reserving CT for children at higher risk.

Booster seat laws and fatalities in children 4 to 7 years of age.

OBJECTIVE: To determine whether state booster seat laws were associated with decreased fatality rates in children 4 to 7 years of age in the United States. METHODS: Retrospective, longitudinal analysis of all motor vehicle occupant crashes involving children 4 to 7 years of age identified in the Fatality Analysis Reporting System from January 1999 through December 2009. The main outcome measure was fatality rates of motor vehicle occupants aged 4 to 7 years. Because most booster laws exclude children 6 to 7 years of age, we performed separate analyses for children 4 to 5, 6, and 7 years of age. RESULTS: When controlling for other motor vehicle legislation, temporal and economic factors, states with booster seat laws had a lower risk of fatalities in 4- to 5-year-olds than states without booster seat laws (adjusted incidence rate ratio 0.89; 95% confidence interval [CI] 0.81-0.99). States with booster seat laws that included 6-year-olds had an adjusted incidence rate ratio of 0.77 (95% CI 0.65-0.91) for motor vehicle collision fatalities of 6-year-olds and those that included 7-year-olds had an adjusted incidence rate ratio of 0.75 (95% CI, 0.62-0.91) for motor vehicle collision fatalities of 7-year-olds. CONCLUSIONS: Booster seat laws are associated with decreased fatalities in children 4 to 7 years of age, with the strongest association seen in children 6 to 7 years of age. Future legislative efforts should extend current laws to children aged 6 to 7 years.

No longer a "nursemaid's" elbow: mechanisms, caregivers, and prevention.

OBJECTIVES: We sought to identify specific mechanisms leading to radial head subluxation, as well as correlation with different caregivers, as a potential platform for education and injury prevention. METHODS: A retrospective cohort study of all patients admitted to an urban pediatric tertiary care emergency department with radial head subluxation from 1995 to 2009 was performed. Cases were identified using a text-search module followed by a manual chart review. We excluded patients with fractures, osteopenia, and neuromuscular conditions. Data collected included age, gender, arm involved, position of the arm at presentation, mechanism of injury, caregivers involved, imaging, and type of reduction. Multivariate logistic regression analysis was used to determine predictors for different mechanisms. RESULTS: There were 3170 cases of radial head subluxation identified. The median age was 2.1 years (interquartile range, 1.5-2.8 years), and 59% were female (95% confidence interval [CI], 57%-60%). There were 2011 patients (63%) presenting with a traction mechanism, 547 (17%) with a nontraction traumatic mechanism, and 612 (19%) with an unknown or undocumented mechanism.Within the traction group, we identified several potentially preventable mechanisms including lifting the child by the arms (28.3%), "wrestling" (12.3%), swinging child by the arms (9.2%), and placing the child into and out of a seat (4.3%). Male caregivers were more likely to be involved when a child is swung by the arms (odds ratio [OR], 3.2; 95% CI, 1.6-6.2), lifted (OR, 1.9; 95% CI, 1.4-2.7), or "wrestled" with (OR, 6.4; 95% CI, 3.3-12.0). Mechanisms common for female caregivers included the child pulling away from parent (OR, 2.3; CI, 1.54 3.4), tripping (2.0; CI, 1.3-3.0), and getting dressed (OR, 2.1; CI, 1.1-4.4). CONCLUSIONS: Radial head subluxation mechanisms can be classified into subcategories, which may be caregiver and even patient gender specific. Provider awareness regarding these mechanisms may help target education and prevention.

Factors associated with the use of cervical spine computed tomography imaging in pediatric trauma patients.

OBJECTIVES: The objectives were to identify patient and hospital characteristics associated with the use of computed tomography (CT) imaging of the cervical spine (c-spine) in the evaluation of injured children and, in particular, to examine the influence of hospital setting. METHODS: This was a retrospective cohort of children younger than 19 years of age from the Massachusetts Hospital Emergency Department (ED) database who were discharged from the ED with an injury diagnosis from 2005 through 2009. Multivariable logistic regression was used to analyze characteristics associated with CT imaging of the c-spine. RESULTS: Of the 929,626 pediatric patients diagnosed with an injury in Massachusetts EDs and then discharged home, 1.3% underwent CT imaging of the c-spine. Rates of CT imaging nearly doubled over the 5 years. In the multivariable model, patient age (adjusted odds ratio [AOR] = 2.3, 95% confidence interval [CI] = 2.0 to 2.7 for children age 12 to 18 years vs. under 1 year of age) and evaluation outside of a pediatric Level I trauma center (AOR = 2.2, 95% CI = 1.1 to 4.3 for children evaluated at non Level I trauma centers vs. pediatric Level I trauma centers; AOR = 2.1, 95% CI = 0.93 to 4.7 for children evaluated at adult Level I trauma centers vs. pediatric Level I trauma centers) were associated with higher rates of CT imaging of the c-spine. CONCLUSIONS: Cervical spine CT imaging for children discharged from the ED with trauma diagnoses increased from 2005 through 2009. Older age and evaluation outside a Level I pediatric trauma center were associated with a higher c-spine CT rate. Educational interventions focused outside pediatric trauma centers may be an effective approach to decreasing CT imaging of the c-spine of pediatric trauma patients.

Validation of a clinical score to predict skull fracture in head-injured infants.

OBJECTIVES: To validate a previously derived clinical score that uses clinical signs to determine which head-injured infants are at risk of skull fracture. The clinical score is calculated on the basis of the patient's age, the scalp hematoma size, and the location of the hematoma, with a total value between 0 and 8. METHODS: We performed a prospective observational study of children younger than 2 years with blunt head trauma presenting to an urban pediatric emergency department. Among subjects who had head imaging performed (validation set), we assessed the utility of our clinical score to detect skull fracture and intracranial injury. RESULTS: In the 203 patients with imaging, 51 (25%) were diagnosed with skull fracture and 29 (14%) with intracranial injury. A clinical score of 4 or greater identified 90% (46/51) of patients with skull fracture with a sensitivity of 0.90 (95% confidence interval [CI], 0.78-0.96) and a specificity of 0.78 (95% CI, 0.70-0.84). A clinical score of 3 or greater identified 93% (27/29) of those with an intracranial injury with a sensitivity of 0.93 (95% CI, 0.76-0.99) and a specificity of 0.42 (95% CI, 0.35-0.50). A score of 3 or greater identified 100% of intracranial injury among asymptomatic patients. CONCLUSIONS: We have validated our clinical scoring system as an accurate way of determining an infant's risk of skull fracture. Whereas a clinical score of 4 or greater maximizes the trade-off between sensitivity and specificity for identifying skull fracture, a clinical score of 3 or greater may be preferable for detecting intracranial injury.

Neuroimaging for pediatric head trauma: do patient and hospital characteristics influence who gets imaged?

OBJECTIVES: The objective was to identify patient, provider, and hospital characteristics associated with the use of neuroimaging in the evaluation of head trauma in children. METHODS: This was a cross-sectional study of children (< or =19 years of age) with head injuries from the National Hospital Ambulatory Medical Care Survey (NHAMCS) collected by the National Center for Health Statistics. NHAMCS collects data on approximately 25,000 visits annually to 600 randomly selected hospital emergency and outpatient departments. This study examined visits to U.S. emergency departments (EDs) between 2002 and 2006. Multivariable logistic regression was used to analyze characteristics associated with neuroimaging in children with head injuries. RESULTS: There were 50,835 pediatric visits in the 5-year sample, of which 1,256 (2.5%, 95% confidence interval [CI] = 2.2% to 2.7%) were for head injury. Among these, 39% (95% CI = 34% to 43%) underwent evaluation with neuroimaging. In multivariable analyses, factors associated with neuroimaging included white race (odds ratio [OR] = 1.5, 95% CI = 1.02 to 2.1), older age (OR = 1.3, 95% CI = 1.1 to 1.5), presentation to a general hospital (vs. a pediatric hospital, OR = 2.4, 95% CI = 1.1 to 5.3), more emergent triage status (OR = 1.4, 95% CI = 1.1 to 1.8), admission or transfer (OR = 2.7, 95% CI = 1.4 to 5.3), and treatment by an attending physician (OR = 2.0, 95% CI = 1.1 to 3.7). The effect of race was mitigated at the pediatric hospitals compared to at the general hospitals (p < 0.001). CONCLUSIONS: In this study, patient race, age, and hospital-specific characteristics were associated with the frequency of neuroimaging in the evaluation of children with closed head injuries. Based on these results, focusing quality improvement initiatives on physicians at general hospitals may be an effective approach to decreasing rates of neuroimaging after pediatric head trauma.

Skull radiograph interpretation of children younger than two years: how good are pediatric emergency physicians?

STUDY OBJECTIVE: We determine pediatric emergency physicians' accuracy in interpreting skull radiographs of children younger than 2 years and determine the characteristics of misidentified skull radiographs. METHODS: A set of 31 skull radiographs (16 with fractures, 15 normal) was compiled from children younger than 2 years who were evaluated for head trauma in a pediatric emergency department from March 3, 1997, to March 3, 1998. A pediatric radiologist reinterpreted the films and agreed with all of the original readings in the final set. Participants (attending level physicians) were asked to identify the presence, location, and pattern of any fracture. Skull radiograph interpretation was considered radiographically correct if the presence, location, and pattern of fracture were correctly identified and was considered diagnostically correct if the presence of a fracture was recognized. RESULTS: Twenty-five of 26 eligible pediatric emergency physicians completed the study. The mean of each participant's radiographically correct interpretation was 65%+/-10% (mean+/-SD), and diagnostically correct interpretation was 80%+/-9%. The group's mean sensitivity for diagnostically correct interpretation was 76%+/-15%, and specificity was 84%+/-14%. Shorter fractures were identified correctly less often (63% < or =5 cm versus 93% >5 cm; mean difference 30%; 95% confidence interval 21% to 39%). Diagnostically correct rates did not differ according to age of patient, physician practice location, years in practice, or practice in ordering skull radiographs. CONCLUSION: Pediatric emergency physicians have limited accuracy in interpreting skull radiographs of children younger than 2 years. Shorter fractures are more commonly misinterpreted.

Role of oblique radiographs in blunt pediatric cervical spine injury.

OBJECTIVE: To determine the usefulness of oblique cervical spine radiography (OCSR) in the management of children who have sustained blunt cervical spine injury, particularly if OCSR is abnormal when no acute abnormalities are shown on standard cervical spine radiography (SCSR). METHODS: We carried out a blinded radiographic review of 109 patients younger than 16 years evaluated at an academic pediatric trauma center and a community hospital between July 1990 and December 1997. All patients had SCSR (anteroposterior/lateral views) and OCSR performed for a trauma-related event within 7 days of injury. RESULTS: In 105 patients (96.3%), radiographic impression after review of SCSR and OCSR did not differ from that after SCSR review alone (95% confidence interval 90.9%, 99.0%). Radiographic impression was revised after OCSR review in 4 patients, all with equivocal findings on SCSR, to normal in three patients and abnormal in one patient (subluxation). Of 78 patients without acute abnormalities on SCSR, no patient had acute abnormalities on OCSR (95% CI, 0-3.8%). CONCLUSIONS: In our series of 109 children who underwent acute radiographic evaluation of blunt cervical spine trauma, oblique views were unlikely to be abnormal if no acute abnormalities were evident on standard anteroposterior and lateral radiographs. Although few patients are likely to benefit from the addition of these views on a routine basis, a useful role for oblique cervical spine radiographs in detecting cervical spine injury in children cannot be excluded based on the results of this study.